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The evidence shows more clearly than ever that having health insurance is essential for people's health and well-being, and safety-net services are not enough to prevent avoidable illness, worse health outcomes, and premature death, says a new report from the Institute of Medicine. Moreover, new research suggests that when local rates of uninsurance are relatively high, even people with insurance are more likely to have difficulty obtaining needed care and to be less satisfied with the care they receive.

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The number of people who have health insurance continues to drop, and employment-based coverage -- the principal source of insurance for the majority of Americans -- is eroding, a situation that is getting worse with the current economic crisis, the report notes. In 2007, nearly one in 10 American children and one in five non-elderly adults had no health insurance. The average amount employees paid per year for family coverage in an employer-sponsored plan rose from $1,543 in 1999 to $3,354 in 2008. If there is no intervention, the decline in health insurance coverage will continue, concluded the committee that wrote the report.

The committee called on the president and Congress to begin efforts immediately to achieve health coverage for all Americans. Steps must be taken to reduce the costs of care and the rate at which health care spending is rising to make that coverage sustainable for everyone, the report adds.

"Policymakers and the public can no longer presume that those without health insurance are getting the care they need through safety-net services such as charity care and emergency departments," said committee chair Lawrence S. Lewin, an executive consultant in health care policy and management. "The evidence clearly shows that lack of health insurance is hazardous to one's health, and the situation is getting worse because of the erosion of employment-based health coverage due to the current economic crisis. The nation must act now to solve the uninsurance problem."

The report responds to key questions being raised in the national debate about health care reform, including whether having insurance is essential for gaining access to necessary services given the availability of charity and free emergency care, and whether lack of coverage has wider ripple effects on whole communities. Written by a committee of experts in medical care, emergency medicine, health policy, business, economics, and health research, the report provides an independent assessment of published studies and surveys as well as newly commissioned research on the impacts of lack of coverage.

A significant amount of new evidence about the health consequences for individuals -- particularly from comparisons of participants' health before and after they enrolled in Medicare, Medicaid, and the State Children's Health Insurance Program -- has emerged since the IOM last studied the consequences of uninsurance in 2004. In addition, new research suggests that that high rates of uninsurance in communities can have spillover effects on the insured.

With health insurance, children are more likely to gain access to a regular source of care, immunizations and checkups, needed medications, asthma treatment, and basic dental services. Serious childhood health problems are more likely to be identified early, and those with special needs are more likely to have access to specialists. Insured children experience fewer hospitalizations and improved asthma outcomes, and they miss fewer days of school.

Adults without health insurance are much less likely to receive clinical preventive services that can reduce unnecessary illness and premature death. Chronically ill, uninsured adults delay or forgo checkups and therapies, including medications. They are more likely to be diagnosed with later-stage cancers that could have been detected earlier, and to die when hospitalized for trauma or other serious conditions, such as heart attack or stroke. Uninsured men and women with cancer, heart disease, serious injury, stroke, respiratory failure, pulmonary illness, hip fracture, and seizures are also more likely to suffer poorer outcomes, greater limitations in quality of life, and premature death. New evidence demonstrates that obtaining coverage lessens or reverses many of these harmful effects.

Based on the available evidence, the committee concluded that when a community has a high rate of uninsurance, the financial impact on health care providers may be large enough to affect the availability, quality, and cost of local services for everyone, even people who have insurance. For example, survey data show that privately insured, working-age adults in areas with higher uninsurance rates are less likely to report having a place to go for care when sick, getting a checkup or routine preventive care, and seeing a specialist when needed. They are also less likely to be satisfied with their choice of physicians or to trust their doctors' decisions.

This report follows a series of six reports the IOM issued between 2001 and 2004 that evaluated how children, adults, families, and communities are affected by lack of health insurance. The series established principles for expanding coverage and culminated with a call for the president and Congress to act by 2010 to achieve coverage for all Americans. The current report reiterates the call for efforts to ensure everyone has access to effective health care services, a need that has not been met through reliance on safety-net services. The committee underscored the urgent need to begin now, given that coverage nationwide continues to decrease as more people lose their jobs and employer-based plans.

The study was sponsored by the Robert Wood Johnson Foundation. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.

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